Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 993279 DEA: 010E0904 EFIS: 0113000123
QA Service Level: 1
DIST-CO-RTE-PM: 01-MEN-20-33.3/34.4
Work Description: CONSTRUCT NEW BRIDGE, REMOVE TWO BRIDGES, EARTHWORK AND PAVING. (Bridge No. 10-0310)
Location Description: MENDOCINO COUNTY NEAR UKIAH FROM 0.3 MILE WEST OF RUSSIAN RIVER BRIDGE AND OVERHEAD TO 0.3 MILE EAST OF COUNTY ROAD 144
Contractor Name: Myers & Sons Construction LLC
Contractor Address: 4600 Northgate Blvd, Suite 100, Sacramento, CA 95838
Resident Engineer: Geoffrey Wright Structure Rep.: Kari Forbes
DIME Sample ID: 2022-10-04-91
TL Number from the TL Form:
Sample Submitted By Organization: CT SC - 3667 - Redwood Valley
Sample Organization Contact: (707) 498-1012
Type of Sample: Quality Assurance
Type of Material: Concrete
Sample Taken Date: 10/04/2022
Date that the sample was received by the laboratory/organization performing the testing: 10/05/2022
The quantity of what the sample constitutes: 167 CY
A brief description of the sample: 4x8 concrete cylinders
From where was the sample collected: Job Site
Laboratory sample identification:
Structure unique identifier: 10-0310
Structure name: Russian River BOH
The fabricator/manufacturer/facility name: NorCal Recycled Rock & Aggregates, Inc.
The concrete mix design number: 718034A
The truck number from where the sample was collected: 9
The batch plant ticket number from where the sample was collected: 42368
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: Back of truck discharge chute
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
